Management of Hemorrhage during Dilation and Evacuation by Mid-Procedure Laparoscopic Uterine Artery Ligation

Abstract

<h3>Study Objective</h3> To present a video demonstrating a multidisciplinary technique for managing hemorrhage during a dilation and evacuation (D&E) via intraoperative consult to minimally invasive gynecologic surgery (MIGS) and laparoscopic uterine artery ligation <h3>Design</h3> Case report. <h3>Setting</h3> Operating room at tertiary care center. <h3>Patients or Participants</h3> 37-year-old gravida 5 para 4 at 22 weeks gestation. <h3>Interventions</h3> A video demonstration of a laparoscopic, bilateral uterine artery ligation with pregnancy in situ to control mid-procedure hemorrhage. After initiating the D&E procedure, brisk bleeding was encountering with an estimated blood loss of 1600 mL within minutes. Options for controlling the hemorrhage were limited, as uterotonics or balloon tamponade were not possible with the pregnancy still in situ, and interventional radiology was not available for uterine artery embolization. An urgent, intraoperative consultation to MIGS was placed. A diagnostic laparoscopy was performed to evaluate for placenta accreta, uterine perforation, or other injury. No hemoperitoneum or defect was noted, however given ongoing heavy vaginal bleeding and potential need for a hysterectomy, the decision was made to proceed with uterine artery ligation prior to completion of the D&E procedure. Starting on the left side, the round ligament was incised, and the retroperitoneum was entered. The perirectal space was developed using the horizontal push-spread technique The uterine artery was skeletonized and ligated at its origin with a vascular clip. This was repeated on the contralateral side. Excellent hemostasis was noted, and the D&E was completed under laparoscopic guidance. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Mid-procedure laparoscopic uterine artery ligation is a feasible option for controlling hemorrhage during second trimester dilation and evacuation when more traditional methods are not feasible or unavailable. A multidisciplinary, subspecialty approach to management of gynecologic complications can help optimize safe gynecologic procedures.